| As I discuss career options with a group of | | | | negotiating? Are psychiatrists more likely |
| third year medical students, I imagine a | | | | to succumb to modesty and self-effacement? |
| marketing brochure for psychiatry residencies | | | | Do psychiatrists have so great a level of job |
| in a world of mental health parity: | | | | satisfaction that they don't worry about |
| | | | money? I wonder if the difference reflects a |
| The brain is undeniably the most complex | | | | much larger problem-- that psychiatrists have |
| organ of the human body. Treatments for | | | | bought into a societal impression that mental |
| diseases of the mind and brain require the | | | | health is less valuable than physical health. |
| intricate understanding of chemistry, | | | | |
| physiology, and anatomy common to all | | | | Support for this last concern can be found |
| branches of medicine, as well as the ability | | | | when one looks at the funding of mental |
| to step outside of oneself to objectively | | | | health services in general, and the tacit |
| observe personality and emotion. The | | | | acceptance of the funding situation by |
| psychiatrist must tolerate the unsettling | | | | psychiatrists and other mental health |
| awareness of the mysterious relationship | | | | caregivers. My insurer is required by |
| between mind and matter, and must help others | | | | statute to provide coverage for mental health |
| find their own answers to the mysteries of | | | | services up to about $2000 per year. On the |
| the human condition. No wonder that the | | | | other hand, there is no limit on payment for |
| masters of medicine-those who work in the | | | | orthopedic injuries. The insured alcoholic |
| vast field of interventional psychiatry-are | | | | is covered for the $1800 surgeon's fee for a |
| so valued by society. | | | | fractured kneecap- and more for the |
| | | | incidental hospital bill and the bills for |
| The time has come for my transition from | | | | physical therapy. If the alcoholic strikes |
| psychiatric residency to psychiatric | | | | his head, the radiologist receives $1200 to |
| practice. The prospect of six-figure incomes | | | | look at the MRI. And if he abruptly stops |
| suggests reward, at last, for years of work | | | | drinking for a week, the hospital is paid |
| and debt. For the employers, under the | | | | tens of thousands of dollars to help him |
| guarantee of income and benefits lies the | | | | through withdrawal-- only to turn him out to |
| expectation of productivity. This | | | | drink again. Yet to treat the primary |
| productivity is not measured by patient | | | | alcoholism, the insurer will pay$2000. And |
| satisfaction, symptom improvement, or reduced | | | | if the patient has spent $2000 for treatment |
| morbidity. Rather the name of the game is | | | | of depression earlier in the year, the |
| the RVU, and the way to get more RVUs is to | | | | insurer will continue to pay for kneecap |
| see more patients in whatever time is | | | | fractures and MRIs, but not for treatment of |
| available. I am grateful for the opportunity | | | | the underlying cause of these |
| to earn good money in the service of a | | | | injuries-alcoholism. And other comparisons |
| challenging and rewarding career. But I am | | | | are equally dramatic. My insurer will pay |
| also aware of the striking difference between | | | | $70,000 or more for cardiac bypass to reduce |
| the salaries of psychiatrists and the | | | | a person's risk of a heart attack, but only |
| salaries of many other physicians. As a | | | | $2000 per year for treatment of the same |
| former practitioner of one of medicine's more | | | | person's depression, to reduce risk of |
| lucrative specialties, I find myself | | | | suicide. The narcotic addict is allowed |
| comparing my apparent value now with my value | | | | $2000 for treatment of heroin addiction, vs. |
| then. Why is my work now worth less than | | | | hundreds of thousands of dollars for a |
| half as much as my work as an | | | | secondary HIV infection. |
| anesthesiologist? | | | | |
| | | | The relatively low payments received by |
| At the end of a night in the crisis service | | | | psychiatrists can be blamed to some extent on |
| last week I walked past a group of patients | | | | psychiatrists themselves. They accept their |
| huddled in the cold, waiting for the doors of | | | | own devaluation when they sign for lower |
| the walk-in clinic to open. As I looked at | | | | salaries or when they accept limitations on |
| their tired faces, I realized the desperation | | | | their ability to practice psychotherapy. |
| they must feel to leave homes or homeless | | | | They allow administrators and others without |
| shelters at such a cold and early hour, and | | | | medical training to dictate treatment plans. |
| make the trek to the clinic by foot or by | | | | I am reminded of the late 1980's when |
| bus. Their pains were certainly as great as | | | | anesthesia was becoming perceived as a |
| the pains of any of my patients presenting | | | | technical trade, and was challenged by the |
| for surgery. But for some reason there is | | | | expanding statutory roles of nurse |
| less outrage over their lack of care than | | | | anesthetists. Rather than narrowing |
| would be the case for a group of patients | | | | anesthesiology, the answer to devaluation was |
| with untreated diabetes, appendicitis, or | | | | found by moving into critical care and pain |
| heart disease standing outside a hospital. I | | | | medicine and asserting the roles of |
| realized that like many in society, I had | | | | anesthesiologists as physicians. Similarly, |
| unwittingly accepted the scene before me as | | | | cardiologists did themselves and their |
| adequate care for the mentally ill. | | | | patients well when they laid claim to |
| | | | angioplasty, and called themselves |
| The RBRVS, or resource-based relative value | | | | interventional'. The new technology brought |
| scale, was instituted by Medicare in 1992 in | | | | public respect and money, which then yielded |
| an attempt to standardize payments for | | | | an explosion of new treatments. I don't know |
| physician services. Relative value units, or | | | | what the parallel path for psychiatrists will |
| RVU's, are assigned to physician services | | | | be, but it is vital that as insights develop |
| based on three main factors: physician work, | | | | into brain function, psychiatrists lay claim |
| practice expenses, and the cost of liability | | | | to them, grasp them, and never let them go. |
| insurance. Physician work is determined by | | | | There is nothing like a brain procedure to |
| several factors including time required for | | | | grab society's interest and respect. In |
| the service, the technical skill and physical | | | | fact, I posit that the simple adoption of the |
| effort, the mental effort and judgment, and | | | | term Interventional Psychiatry' would |
| the amount of stress experienced by the | | | | increase the funding of psychiatrists and |
| physician due to the risk to the patient. To | | | | psychiatric research by 20%. |
| arrive at the fair value' of services, the | | | | |
| number of relative value units is multiplied | | | | The low priority of mental health services to |
| by a universal dollar value, and adjusted | | | | society is, of course, a complex issue. |
| slightly for practice location according to | | | | Stigma, lack of lobbying resources, and |
| regional cost of living indices. | | | | denial of the impact of mental illness |
| | | | certainly play roles in the lack of public |
| In theory, this approach to payment provides | | | | interest and investment in mental health. |
| a level playing field for physicians. | | | | Resources are thin for the unemployed and |
| Payments for a cholecystectomy, for example, | | | | uninsured mentally ill, and the field of |
| reflect the fortitude one must have to cut | | | | psychiatry deserves kudos for attempting to |
| into someone's body and the time required for | | | | meet the needs of this population in return |
| surgery and postoperative care. Medicare | | | | for little financial gain. But for patients |
| strictly adheres to this formula, but in the | | | | with resources, we must recognize and |
| world of private insurance some physicians' | | | | advocate that mental health care is as |
| relative value units are more valuable than | | | | important as treatment for a torn ACL, and |
| others. In my region, for example, Medicare | | | | deserves equitable reimbursement. The |
| has decided that the relative value of a unit | | | | abilities to laugh, to work, and to love are |
| of physician work is about $38. The largest | | | | as vital as the ability to return to beach |
| third-party payer in the area will pay | | | | volleyball. Psychiatrists must realize that |
| psychiatrists, pediatricians, or family | | | | at some point, expectations of relatively low |
| physicians about $50 per value unit. But | | | | reimbursements and medical standing become |
| orthopedists and radiologists, or podiatrists | | | | self-fulfilling prophecies, as our society |
| providing orthopedic services, are paid $100 | | | | tends to value those most who value |
| per value unit. | | | | themselves. The correction of societal bias |
| | | | and the resultant devaluation of our services |
| What accounts for the difference in payment? | | | | will require constant efforts to educate, |
| If not due to stress, physical or mental | | | | negotiate, and assert the value of mental |
| effort, risk, technical proficiency, or | | | | health care in a healthy society. And |
| practice cost, where does the difference come | | | | psychiatrists, as the voices, faces, and |
| from? Certainly not from supply and demand, | | | | business representatives of mental health, |
| as in my area it is much easier to see an | | | | will raise the status and treatment of their |
| orthopedist this week than to see a | | | | patients as they work to raise the |
| psychiatrist within the next month. Does the | | | | scientific, and yes, economic, status of |
| lower reimbursement reflect decades of poor | | | | themselves as physicians. |